Medical Surgical department

‫قسم التمريض الباطنى والجراحى‬

Medical-Surgical Nursing I (100102)
Academic year 2020/2021 - Second Semester - First year, Second level

Nursing Assessment Sheet

-Student's Name: -Section:
- Group No. -Date:
Patient's Socio-Demographic Data

Patient's name: ………………………………………………….….

Department: ………………………………………………………..
Date of admission: ………………………………………………….
1- Age in years:
a) 20 ˃ 30 ( )
b) 30 > 40 ( )
c) 40 > 50 ( )
d) 50 ≥ 60 ( )

2- Gender:
a) Male ( )
b) Female ( )

3- Marital status:
a) Single ( )
b) Married ( )
c) Divorced ( )
d) Widow ( )

4- Level of education:
a) Illiterate ( )
b) Can read and write ( )
c) Primary ( )
d) Secondary ( )
e) University ( )
f) Others ( )

5- Area of residence:
a) Rural ( )
b) Urban ( )

 Pattern of admission.
- Private physician ( ) Outpatient clinic ( ) Emergency unit ( )
 Diagnosis:-……………………………………………………………
 Name of operation:-………………………………………………….
 Date of operation:-…………………………………………………….
 Postoperative days:-……………………………………………………
 Health history :
a. Reason for Hospitalization:
…………………………………………………………………………

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 b. Chief Complaint:
………………………………………………………………
 Location:
 Duration:
 Onset: Sudden ( ) Gradual ( )
 Aggravating factors:
 Alleviating factors:
Associated factors:

Medication:
- Prescribed No Yes
- Over counter No Yes
Smoking:
- Smoker No Yes

-Passive smoker No Yes

- Quitter No Yes
Alcohol intake: No Yes
Nutrition: - Frequency (___meals/day)
- Likes and dislikes__________________
- Amount of fluid intake ____L/day
- Dietary intake: -Ordinary ) ( -Therapeutic ( )

If therapeutic specify………………………………………..
…………………………………………………………………..
………………………………………………………………….
…………………………………………………………………

Item Please circle If (yes) Specify

 Past history
Previous hospitalization No Yes
Associated diseases No Yes
Previous surgery No Yes
Allergies No Yes
Previous blood transfusion No Yes Type ____Amount ____Time ____
 Family history
Cancer No Yes
Hypertension No Yes
Diabetes Mellitus No Yes
Kidney disease No Yes
Asthma No Yes
Heart disease No Yes
Liver disease No Yes
Others No Yes

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 Lifestyle/health patterns/habits
Elimination - Bowel frequency ________
- Constipation( ) -Diarrhea( ) - Others( )
- Urinary frequency____/day
- Attached catheter Yes ( ) No ( )

- Voiding pattern * One stream( ) *Reluctant ( )

* Dripping ( ) * Others ( )
* Suprapupic ( ) * Flank( )
- Pain Assessment
.......……………………………………………… *Incontinence )
( *Others ( )
- Amount *Normal( ) * Polyuria ( ) * Oliguria( )
*Anuria ( ) *Nocturia ( ) *Pyuria ( )
* Hematuria( ) *Dysuria( ) * Retention(
Sleep - Sleep hours: Day____ Night____
Level of activity: - Independent …………….
- Partial independent ……………
- Dependent ……………
 Physical Examination:
1. Physical examination
 General appearance:
* Consciousness: Conscious____ Altered____
* Patient's posture: Normal____ Scoliosis____ Kyphosis ____Lordosis____
* Grooming : Tidy____ Untidy____ * Hygiene: Good____ Poor ____
* Weight: Normal ____Thin ____Obese____
* Gait: Normal____ Abnormal____
 Vital signs:
1. Temperature ______
2. Pulse: rate_________ rhythm _________
3. Respiration: rate_____ rhythm _____ depth ____
4. Blood pressure: value_____ site: ______ Position______
5. Pain: site _______ severity _______ onset ---------- duration _______
character -----------
Increasing factors …………. Decreasing factors …………..

10 9 8 7 6 5 4 3 2 1 0

Worst No pain
pain

Item Please circle If (yes) Specify

Amount and Normal Abnormal Brittle ______ Alopecia_____
distribution of hair
Head

Presence of lice No Yes

Presence of dandruff No Yes
Scalp Intact Not intact Scratches______ Lesions____
Others No Yes
Color Healthy Unhealthy Pale _____Cyanotic _____Yellow
______
Face

Eye
Vision Normal Impaired Prosthesis____ R/L
Color Normal Abnormal
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 Others No Yes
Ear
Hearing Normal Impaired Prosthesis____ R/L
Presence of discharge No Yes
Item Please circle If (yes) Specify
Others No Yes
Nose
Patency Patent Not-patent
Position of nasal Normal Abnormal
septum
Smile Normal Abnormal
Others No Yes
Mouth
Lips Normal Abnormal Moist ____ Dry ____
Cracked ____
Mucus membrane Normal Abnormal Ulcers____ Patches____ Dry____
Bleeding____
Teeth Intact Lost Denture____
Odor Absent Present

Tongue Normal Abnormal Ulcers____ Coated____Dry___

Neck
Inspection
Jugular veins Flat Congested

Position of trachea Midline Deviated

Old scar
Palpation
Lump Present Absent
Swelling Present Absent
Lymph node Present Absent
Manipulation Free Limited
Range of motion Yes No

Others No Yes

Inspection Barrel____ Kyphosis____

- Shape of chest wall Normal Abnormal Funnel____ Pigeon____
- Chest movements Equal Unequal
- Using of accessory
No Yes
muscles
- Others No Yes
Chest

Palpation
- Chest expansion Equal Unequal
- Tenderness No Yes
- Lumps No Yes
Tactile fremitus sound Normal Abnormal
- Others No Yes
Percussion Flatness___ Dullness__
- Percussion sound Resonant Abnormal Hyper resonant___ Tympany____
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 Auscultation Bronchial vascular
- Air entry Bil-equal Diminished bronco vascular
- Breath sounds Normal Abnormal Wheezing____ Crackles____
Rhonchi____
- Apical pulse Rate_________ Rhythm _________
- Others No Yes Chest pain__ Cough__
Dyspnea__
Item Please circle If (yes) Specify
Inspection
- Shape Normal Abnormal Distension ____Ascites____
Hernia____
- Skin integrity Intact Abnormal Scars____ Rashes____
Auscultation
- Bowel sounds Present____ Hypoactive____ Hyperactive____
Palpation Absent__
Abdomen

- Tenderness Present____ Absent__

- Lump Present____ Absent__
Present____ Absent__
- Distention Present____ Absent__
Percussion Present____ Absent__
-Dullness
--Tympanic
- Others No Yes Anorexia __ Pain__ Nausea
__ Constipation __ Diarrhea __
Incontinence__ Vomiting------------

Inspection Normal Abnormal Cyanosis____ Pale____

Skin color Yellowish____
Skin integrity Intact Abnormal Scars____ Lesion ____
Skin temp. Warm Abnormal Hot ____Cool____ Moist____
Varicose veins Yes No Site
Upper & Lower Extremities

Nail color Normal Abnormal

Nail shape Normal Abnormal Clubbing ---------- brittle -----------

Palpation
Skin turgor Elastic Inelastic Dry____
Sensation Normal Abnormal Parasthesia ___ Numbness ___
Edema Site _______Type
No Yes
______Degree______
Capillary refill  3 sec Abnormal  3 sec ____
Manipulation
Joints Free Limited Swelling __ Deformed__
Redness__
Others No Yes
Cervical Non Palpable
palpable
Lymph
Nodes

Axillary Non Palpable

palpable
Femoral Non Palpable
palpable
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 Temporal Present Absent
Carotid Present Absent
Peripheral Pulse
Brachial Present Absent
Radial Present Absent
Femoral Present Absent
Popliteal Present Absent
Posterior Tibial Present Absent
Dorsalis pedis Present Absent
 Psychological status

-Anxiety ( ) - Fear ( )
- Response of patient: * cooperative ( ) *Passive ( ) * Active ( ) * Aggressive ( )
- Sleep : * Normal ( ) * Altered ( ) If yes specify…………………………….
-Manner of communication: *Talks freely ( ) *Reluctant ( ) * others ( )

Laboratory & Diagnostic findings:

a. Abnormal laboratory studies
Name of test value Name of test value

b. Diagnostic studies
Name Date Result

 Current Medications:
Name Dose Route Frequency Name Dose Route Frequency

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 List of Patient’s Problem:

1. …………………………………………………………………

2. …………………………………………………………………

3. …………………………………………………………………

4. …………………………………………………………………

5. …………………………………………………………………

6. …………………………………………………………………

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